Reports preface a poor prognosis for general practice

Here we unravel the draft National Primary Healthcare Strategy, and further delve into the implications of the NHHRC for general practitioners.

In July 2009, the National Health and Hospitals Reform Commission (NHHRC) report [LINK] threatened to change the face of general practice. Last month, the draft National Primary Healthcare Strategy was released, offering little comfort to general practitioners.

These two reports are calling for a revolution in primary care. Whether general practitioners are to be martyred up against the wall, or part of the brave new future of primary health care, is going to be decided over the next few months.

The past ten years have seen improved efficiency in general practice, particularly with new technology. This has been fortunate, as rebates have failed to keep up with inflation and failed dismally to keep up with the real costs of providing quality care. General practice has been squeezed hard, and is hurting.

In a climate where general practice representation is fragmented, rebates are being squeezed and there is a government-precipitated workforce crisis, the growing calls for improvement are justified. General practice has proven time and again to be the most cost-effective health care available worldwide – and building on what works and fixing what doesn’t must be the basis of reform.

The NHHRC and Primary Healthcare Strategy reports seem to suggest that general practice is going the way of the dodo. According to the NHHRC report, there are too many ‘stops’ on the patient journey – general practice should be providing more services.

Most practices have enough doctors in the practice. They don’t have enough nurses… or chiropractors. Pretty much every general practice in the country is short on neurosurgeons. Most don’t have a pharmacy on site.

Large general practices can be very effective. Many doctors enjoy working in them, and many patients welcome the convenience of having several services on site. Medium sized general practices can also provide quality care and support to their communities, and many patients prefer more local, more personalised health care.

The reports call for larger mega-practices, or ‘superclinics’, with a suite of services available. The NHHRC has recommended that Australia have 300 Comprehensive Primary Health Care Centres. AMA is yet to be convinced that having only 300 practices will improve access to the Australian community.

The governance structures of the proposed Comprehensive Primary Health Care Centres are also of interest. Many would evolve from existing general practices and mergers (both physical and virtual), but there is a danger that practice ownership and clinical control may be out of reach of new and younger GPs.

The NHHRC report calls for the Divisions of General Practice to be abolished, to be replaced by between 40 and 80 Primary Healthcare Organisations. These PHOs would have governance to reflect the diversity of clinicians and services forming comprehensive primary health care — a none-too-subtle suggestion that GP control of Divisions is unlikely to translate into control of PHCOs.

There are also fundamental changes planned for primary care service funding. Both reports are a bit vague on the ways forward, but both recommend reducing the reliance on fee for service medicine. AMA supports additional funding mechanisms that will improve access to multidisciplinary teams, such as practice nurse rebates and better access to allied health, but both reports seem to be advocating a move toward fund holding and independent access to MBS-funded services.

AMA has generally opposed fund holding, believing that it is the responsibility of governments to explicitly ration health care, rather than rely on general practice or a third party determining the level of care.

Fund holding in the United Kingdom has resulted in decreased access to medical care, reduced choice, long waiting times and the most vulnerable in the community missing out on care.

The third party, insurance-led care in the United States means that some patients get excellent care, and others miss out. Long waiting times for care are common, and several million people have very poor access to care.

One area for keen debate is patient enrolment. Would patient enrolment improve continuity of care, or is it the thin end of the fund holding wedge?

AMA supports a model where general practice is the centre of care, bringing together teams of nurses and allied health providers both within the general practice and in other practices. There is great benefit to patients and to the community of general practitioners being the gateway to specialist care, and there are many studies demonstrating that a general practice-led health system provides better health outcomes.

The current funding models do not support best patient care. AMA has been advocating for a revamped Medicare Benefits Schedule that rewards GPs for spending more time with their patients, increases the use of practice nurses and allied health, and ensures the patient has continuity of care.

There are two basic types of changes — that which you do, and that which is done to you. There are many opportunities in times of change, and AMA will be working hard to ensure that general practice is strengthened and enhanced through the reform process.